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± SAN JOAQUIN LOCAL. HEALTI�DISTRICT <br /> -OFFICE USE: 1601 E. Hazelton Ave. , Stockton, CA 95205 Permit <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued x/-.� z-7� <br /> (Eomplete .In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br />,and/or install the work herein described. This application is made in compliance with San <br />,Joaquin-County Ordinance No. 1862 and the Rules and' Regulations of the San Joaquin Local Health <br /> ,District. <br /> 4EXACT STREET- ADDRESS__4.7,67 MAIN CITY/TOWN <br /> (Owner's Name 7- ra 45� '*- 7- Phone 0s.P <br />.,Address _,g- City S 776e.r 7-4 / <br /> Contractor's Name License# Phone <br /> 'IS CERTIFICATE -OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH-SJLHD? YES 0 � <br /> STYPE OF WORK (Check) : NEW WELL b DEEPEN ❑ RECONDITION DESTRUCTION <br /> WELL CHLORINATION 0 WELL ABANDONMENT Q OTHER 0 <br /> PUMP INSTALLATION M PUMP REPAIR 0' PUMP- REPLACEMENT [ V <br /> ;_DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> r. SEWAGEIDISPOSAL F ELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE D MESTIC WELL PUBLIC D MESTIC WELL , <br /> INTENDED USE' TYPE OF-WELL.. CONSTRUCTION SPECIFICATIONS <br /> Industrial Caba Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia, of Well Casing <br /> Domestic/public - Driven Gauge of Casing <br /> Irrigation IGravel Pack Depth of Grout Sea <br /> Cathodic Protection ) Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical j Surface Seal Insta a by: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> I., _ <br /> PUMP REPLACEMENT: M State Work Done <br /> PUMP REPAIR: Q State Work Done <br /> DESTRUCTION OF WELL: Well Diameter " Approximate Depth /5"Q ��- <br /> - Describe MaterialandProce ure <br /> I <br /> thereby certify that I have prepared this application and that the work will be done in accordance <br /> with San Joaquin County Ordinances, S.tate Laws , and Rules and Regulations of the San Joaquin Local <br /> Health District. Home owner or licensed -agent's signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, I shall <br /> not employ any person in such manner as to become subject_ to Workman's Compensation -. <br /> laws of California.,, <br /> I WILL CALL FOR A GROUT NSPECTION PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED jj���� TITLE: � ,, DATE: p17,30 <br /> (DRAWPLOT PLTN ON <br /> REVERSE SIDE <br /> PHASE I <br /> DEP RTM ONLY - <br /> PPLICATION ACCEPTED SY DATE. Z `T <br /> ADDITIONAL COMMENTS: , <br /> PHASE 11 GROUT INSPECTION PH I L INSPECTION <br /> INSPECTION 8Y DATE INSPECTION DATE <br /> EH 14 26 Rev., 9/78 - 9/.78 2M <br />